Health inspection·October 5, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some regarding the physical condition of Resident #51's room. Resident #51's family member stated when they moved Resident #51, they were told the facility is being renovated, and the family member has yet to see anything done. Resident #51's family member stated concerns were brought forward about the dust on the vent above Resident #51's bed and the black substance on the walls, not to mention the odor and nothing has been done. Observation at the time of the interview revealed the vent in the right side of the room, above the bed of Resident #51 contained a thick layer of dust that covered the openings of vent and a black substance at the base of the wall surrounding the recessed dresser. The black substance smeared when touched. Interview on 10/04/23 at 11:40 A.M., with Maintenance Supervisor #208 revealed the facility had started to renovate the first week in June 2023, however, there have been issues that have prevented the renovations to occur as originally scheduled. Observations on 10/04/23 beginning at 12:00 P.M., with Maintenance Supervisor #208 confirmed blinds and window coverings were broken and torn, the hole in the wall of Resident #11's bathroom, a substance on the walls of resident rooms, peeling and cracked drywall, dust, and odors in the facility especially on the east wing of the building. Maintenance Supervisor #208 verified the conditions were unacceptable for the residents. This deficiency represents non-compliance investigated under Master Complaint Number OH00146847 and Complaint Number OH00146411. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain a clean, functional, sanitary, and homelike environment for its residents. This had the potential to affect all 43 (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85 and #86) residents residing on the east wing of the building and affected seven residents (#3, #4, and #12) of 43 residents residing on the west wing of building. The facility censuses were 86. Findings include: Observations during tour of the facility on 10/04/23 between 9:10 A.M. and 10:15 A.M., revealed on the east wing, there was a strong foul odor noted as soon as one passed through the secure double doors. In the activity room/dining room, a cupboard door above sink, was hanging loosely off the cupboard by the right lower hinge; a missing front panel on the top drawer to the left of the sink; and sticky floors. Across from the nurse's station, the corner of the wall was cracked and crumbling with exposed drywall, with a jagged broken metal corner piece exposed to the hallway. The screen on window at the end of hall outside rooms [ROOM NUMBERS] was torn and hanging a quarter way down off the window closet to the emergency exit door. Ceiling tiles are not seeded in the tracks with several tiles stained brown and yellow in hallway outside Resident #70 and #71's room. A missing right closed door with the left closet door off the track with cracked and crumbling drywall and an exposed bent metal stripping hanging off the corner of the wall just outside the closet of Resident #75 and #76's room. A black substance that extended from the floor to waist high on the three walls surrounding the dresser in the room of Residents #62 and #63. The black substance smeared when touched. Continued tour on the west wing of the building revealed bowed, cracked, and yellow stained ceiling tiles outside room [ROOM NUMBER], missing blinds and curtain with a bath blanket hanging over the left window and three exposed rods for hanging curtain, sticking straight off wall, over the bed of Resident #4's bed, walls along the wall next to Resident #4's bed had two visible holes with white tape covering. Missing and broken white trim pieces along the half walls in the rooms of Residents #3, #4, and #12 with exposed bare wood was observed. Interview on 10/04/23 at 10:04 A.M., with Licensed Practical Nurse (LPN) #148 verified the foul odor on the east wing and did not know what it was. Interview on 10/04/23 at 10:30 A.M. with Certified Nursing Assistants (CAN) #116 and #136 verified the black substance on the walls of Residents #4's room. CNA #116 stated the black substance has been on the walls for several months. CNA #116 and #136 both verified they have submitted work orders to have the issue addressed and further stated no one does anything about it. Interview on 10/04/23 at 11:40 A.M., with Maintenance Supervisor #208 revealed the facility had started to renovate the first week in June 2023, however, there have been issues that have prevented the renovations to occur as originally scheduled. Observations on 10/04/23 at 12:00 P.M., with Maintenance Supervisor #208 confirmed the foul odor on the east wing, the torn screen, verified broken and missing cupboard doors, blinds and window coverings were broken and torn, there were a substance on the walls of resident rooms, peeling and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm cracked drywall and exposed metal striping. Maintenance Supervisor #208 was observed seeding ceiling tiles into the track during the tour and agreed the conditions were unacceptable for the residents. This deficiency represents non-compliance investigated under Master Complaint Number OH00146847 and Complaint Number OH00146411. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 4 of 4